Healthcare Provider Details

I. General information

NPI: 1265804587
Provider Name (Legal Business Name): AMY BERRY MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 DOCTORS PARK
GIBSON CITY IL
60936-2000
US

IV. Provider business mailing address

1120 N MELVIN ST
GIBSON CITY IL
60936-1477
US

V. Phone/Fax

Practice location:
  • Phone: 217-784-4030
  • Fax:
Mailing address:
  • Phone: 217-784-4251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7631
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149020871
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: